Neurology

Brain

Stroke

• H&P: Ischemic stroke has same risk factors same as ASCVD, with addition of afib, endocarditis, mechanical valve, cardiac shunt. BE FAST. NIHSS. Permanent neurological deficits. Hemorrhagic stroke risk factors include hypertension, blood thinner, trauma, smoking, cancer.
• Dx: Ischemic vs. Hemorrhagic. Can localize stroke based on symptoms. NCCT head to rule out hemorrhage; CTA, MRI to look for filling defects and ischemic injury; TTE, telemetry to evaluate for afib. Differential includes TIA, seizure.
• Tx: For ischemic stroke, give tPA within 4.5 hrs of symptom onset, otherwise hep gtt. If large occluding clot in major vessel, can do endovascular thrombectomy within 24 hrs. Contraindications to tPA include recent major surgery, history of hemorrhagic stroke, Plt < 100k, INR > 1.7, age < 18, intrabdominal bleed.

Hematoma

Hematoma Types

	Vessel affected	History	Imaging
Epidural	Middle meningeal artery	High energy impact (e.g. MVA), Lucid interval	Lens shaped (high pressure arterial bleed compresses brain); doesn't cross suture lines
Subdural	Bridging veins	Old person or alcoholic with a fall (low energy)	Crescent shaped (low pressure venous bleed doesn't compress); may cross suture lines

Headache

Primary Headache Disorders

	H&P	Treatment	Prophylaxis
Migraine	F > M, throbbing, unilateral, aura, nausea, vomiting, photophobia, phonophobia, visual disturbances, family history, hours to days	NSAIDs, SQ triptans, CGRPs	AEDs (topiramate, valproate), Beta blockers (propranolol), Verapamil, low-dose TCAs (amitryptaline), zonisamide, botox, CGRPs
Cluster	M > F, sharp/stabbing, unilateral, retro-orbital, occurs at the same time each day, resolves quickly; exam reveals Horner syndrome, ipsilateral nasal congestion, conjunctival injection, lacrimation	100% O2, SQ triptans	AEDs (topiramate, valproate), Verapamil, lithium, steroids
Tension	dull/tight/pressure, bilateral, band-like, can extend into the neck and shoulders, triggered by stress, lasts up to 7 days	NSAIDs/APAP, massage, heat, relaxation	Avoid triggers

Seizure

• H&P: Aura, symmetrical rhythmic convulsions, eyes deviate towards contralateral side, lateral tongue lacerations, bowel/bladder incontinence, post-ictal state, post-seizure myalgias, can have transient weakness that mimics stroke (Todd paralysis)
• Dx: EEG. Differentiate between focal (simple and complex) and generalized (grand mal, petit mal, myoclonic, atonic). Differential includes metabolic (hepatic encephalopathy, hyponatremia, hypomagnesemia, hypercalcemia, hypoglycemia), infectious (meningitis), intoxication (or drug withdrawal), neoplastic (brain tumor), vascular (aneurysm, stroke, hemorrhage, dissection). Get CBC, BMP, LFTs, urine tox screen, AED levels, consider MRI
• Tx: AEDs (no first line agent, decide on a case-by-case basis). For status epilepticus, ABCs, give IV lorazepam, fosphenytoin if seizure persists, consider induced coma if all else fails.

Brain Death

• Dx:
  • Must have SBP > 100, temp > 36°C, PaCO2 35-45, euvolemia, off all sedatives
  • If above conditions are met, test for brainstem reflexes: pupillary reflex (II, III), corneal reflex (V, VII), doll's eye reflex (III, IV, VI, VIII), and gag reflex (IX, X)
  • If no brainstem reflexes, do apnea test: positive if no breathing when PaCO2 is 60 mmHg or 20 mmHg higher than patient's baseline
  • If apnea test is equivocal, can do four vessel angiography, EEG, or duplex US
  • Rule out secondary causes of coma (e.g. test for severe hypoglycemia)
• Tx: If two physicians agree on diagnosis, withdraw care (even in absence of family agreement)

Vertigo

• H&P: Differentiate between dizziness and lightheadedness. Peripheral and central vertigo present differently. Peripheral is positional, improves with eye fixation, and
• Dx: BPPV, MS, Meniere disease
• Tx: Treat underlying cause. For BPPV, the Epley maneuver, PT, antihistamines, and benzos can all help.

Spinal Cord

Spinal Cord Compression

• H&P:
• Dx: Sensory level, pain, weakness, numbness, or hyperreflexia below the level of compression, bowel/bladder incontinence and saddle anesthesia with caudal equina. Differential includes tumor, disc herniation, osteomyelitis, epidural abscess, aneurysm, epidural/subdural hematoma, fracture
• Tx: Based on etiology. Don't give steroids for infection. May need neurosurgical decompression.

Spinal Stenosis

• H&P: Neurogenic claudication-low back pain that radiates to the buttock that is worse with spinal extension, walking downhill, and standing, better with walking downhill and leaning forward. Negative SLR.
• Dx: Degenerative changes and neuroforaminal narrowing on xray or MRI.
• Tx: NSAIDs, PT, multimodal, MNB, MND, ESI, laminectomy

Transverse Myelitis

• H&P: Inflammatory spinal cord process without compression but with weakness, numbness, and autonomic dysfunction below the level of the lesion.
• Dx: Bright area on MRI. Test CSF to rule out HSV, VZV, Lyme, MS.
• Tx: Glucocorticoids. Plasma exchange.

Cord Syndromes

Spinothalamic, corticospinal, rubrospinal, dorsal columns, anterior horns, dorsal horns

Spinal Cord Syndromes

Syndrome	Spinal Tracts Involved	Presentation
Syrinx	Spinothalamic decussation at ventral commissure, then corticospinal tracts	Loss of pain and temperature bilaterally at the level of the lesion, followed by weakness
Brown-Sequard	Hemi-cord dissection	Contralateral loss of pain and temperature, ipsilateral weakness and loss of light touch, vibration, and proprioception
Anterior	Spinothalamic, Corticospinal	UMN syndrome at the level of the lesion, loss of pain and temperature below the lesion
Posterior	Dorsal columns	Loss of light touch, vibration, and proprioception bilaterally below the level of the lesion